Module 2: Mental Health in Refugee Camps and Settlements

Causes of Mental Health Problems in Refugee Populations

While living in their home country, refugees often experience traumatic events and adverse situations such as sexual violence, genocide, torture, political persecution, and the loss of loved ones, which frequently prompt them to leave their country of origin. For instance, a study done in 2003 on Somali refugees in a Ugandan refugee settlement found that 73.5% of those surveyed reported witnessing dead or mutilated bodies, while 69.3% reported witnessing or experiencing a shelling or bomb attack.(1) Unfortunately, these difficult circumstances do not let up once the refugees escape from their home country. Refugees often must travel arduous lengths without food or water to get to the camps. For example, the Lost Boys of Sudan, a group of 40,000 orphaned boys, walked thousands of miles to Kakuma Refugee Camp in Kenya while fighting starvation and wild animals in order to escape political persecution and genocide.(2) Moreover, once the refugees arrive at the camps, they are often confronted with additional adverse situations and ongoing stressors, which substantially impact their mental health. For example, the poor quality of accommodations, restricted economic opportunity, and uncertainty over access to food and water are major psychological stresses. When then first lady Rosalynn Carter visited Sa Kaeo, a refugee camp in Thailand for Cambodian refugees, she found that it was built on a rice paddy and had poor drainage. She described the unfortunate living conditions in the camp and remarked, "we discovered a virtual sea of humanity . . . they were lying on the ground, on mats or dirty blankets or rags. All were ill and in various stages of starvation; some, all bones and no flesh; and others with crackled feet and swollen as though to burst."(3)

Similarly, in some instances the refugee camps themselves may have problems with safety and security. For example, following the Rwandan genocide of 1994, many Hutu escaped into neighboring Democratic Republic of Congo and other bordering countries as the Tutsi took over power. During that time the Tutsi sought revenge against Hutus they believed were responsible for the 1994 genocide. Not surprisingly, among the fleeing 'refugees' were war criminals, who used the refugee camps in the Democratic Republic of Congo as a base and cover to launch attacks against the new Rwandan government. These Hutu militiamen used fear tactics and propaganda in order to recruit allies and fighters from within the refugee camps. These tactics furthered violence in the area and severely affected the psychological health of refugees who were already recovering from the genocide.(4)

Similarly, it is not only traumatic events or experiences that affect the mental health of refugees. Recent work has shown that the daily hassles of living in refugee camps, such as waiting in line at the water tap, also negatively impact mental health. Though the stresses of everyday life at a refugee camp are known to negatively impact health, the good news is that since "daily hassles seem to be reliable predictors of distress among war-affected populations… they may also be promising targets for interventions."(5) Lastly, when refugees leave the camps, they often are resettled and sent to a foreign country where they have to endure new stresses, such as the everyday struggles of living in a new country, mourning the loss of loved ones, and coming to terms with their cultural identity.(6) Because refugees have witnessed and experienced many traumatic events, as well as multiple and chronic adversities, they have a high risk of developing mental health problems and have a higher prevalence of psychological disorders, particularly depression and post-traumatic stress disorder (PTSD).(7) PTSD is an anxiety disorder which often occurs after witnessing or experiencing an event that is personally threatening. The most common symptoms of PTSD are repeated reliving of the event, avoiding anything or anyone that might elicit memories of the event, and excessive awareness and response. Risk factors for PTSD include life threat, forced evacuation and displacement, and economic hardship, which are all obstacles that refugees face.(8) A survey conducted among Sudanese refugees living in northern Uganda found that PTSD was prevalent among 50.5% of the refugees.(9) PTSD and depression are particularly problematic because they have such long lasting effects; "even two decades after the trauma experienced in Cambodia, studies show that 62% of adult refugees still suffer from PTSD and 51% suffer from depression."(10) In addition, refugees frequently mention being plagued by feelings of hopelessness, fear, sadness, anger, aggression and worry.(11)

Mental Health Among Children

"No child should see this. It is the end of childhood, when you see your mother's face slacken, her eyes dead. When she is defeated by simply seeing the threat approaching. When she does not believe she can save you."(12)

Because of the cumulative stressors that they have experienced, refugee children are also at a high risk of developing emotional and behavioral problems. Children may arrive at refugee camps alone, often having witnessed the death of a parent or loved one and having experienced or witnessed violence and torture.(13) Refugee children are particularly vulnerable to developing mental health problems when they are in the process of moving to refugee camps, as they are frequently separated from their parents or guardians, or their parents may be too overwhelmed or otherwise unable to attend to their emotional needs.(14) The Lost Boys of Sudan were one such group. These boys were orphaned or separated from their families during the Second Sudanese Civil War, and many walked thousands of miles to Ethiopia or Kenyan refugee camps. Valentino Achak Deng, a Lost Boy now living in the United States, explained that "in the group, there were many boys who became strange. One boy would not sleep, at night or during the day. He refused to sleep for many days, because he wanted always to see what was coming, to see any threats that might befall us."(15) Having to live through such traumatic experiences can clearly make children (and adults) hyperaware of their surroundings, which negatively impacts their ability to function both on a basic and higher level. Additionally, some refugee children have been coerced to join militias as child soldiers. These children are often deeply traumatized and go through disarmament, demobilization, and reintegration (DDR) programs upon entering refugee camps. Unfortunately, the effectiveness of these programs depends on the administrative capacity of the particular refugee camp, and many former child soldiers do not have this type of support.(16) It is also important to note that it is not just first-generation refugee children who suffer from mental illnesses as a result of trauma. Second-generation refugee children are at a high risk of suffering from behavioral conditions, such as substance abuse and eating disorders.(17) Fortunately, not all children who experience war trauma develop mental illnesses or behavioral problems. High socioeconomic status and social support from family members are all protective factors that enhance a child's resilience.(18) Because families act as stress buffers for traumatized children, efforts should be made to strengthen parental support to help vulnerable children.

The Importance of Addressing Mental Health

It is important to address the mental health of refugees because mental illness severely impacts the functioning of a person in many ways and can also contribute to poor physical health. For example, mental illness often negatively impacts the ability of an individual to engage in economically productive activities, to benefit from educational opportunities, and raises the risk of substance abuse and family dysfunction.(19) Thus, in order to ensure the refugees' successful adaptation and functioning after resettlement, it is critical to identify and treat mental illness.

Mental Healthcare Delivery

Though it is now recognized that the mental health needs of refugees are great, often refugees will not seek mental health care because they are either unfamiliar with the concept of mental health, or they associate a stigma with it.(20) Thus, initiatives are needed to overcome these barriers to care. One such initiative was carried out by the International Center for Psychosocial Trauma at the University of Missouri, Columbia. The center has taught strategies to over 6,500 teachers, mental health professionals, and volunteers about how to alleviate childhood posttraumatic stress disorder and depression. By training teachers as therapists, many obstacles that normally impede care can be overcome, and children can receive early help and assistance.(21) By training locals in the community and prominent refugees who speak their dialect, they are able to assist with mental health consultancy in a way that makes refugees feel more comfortable with the discussions.

Footnotes

(1) Onyut, L. P., Neuner, F., Ertl, V., Schauer, E., Odenwald, M., & Elbert, T. (2009). Trauma, poverty and mental health among Somali and Rwandese refugees living in an African refugee settlement - an epidemiological study. Conflict and health. 3(1), 6.

(2) "A Brief History." Help Sudan International.

(3) Reedy, J. (2007). The Mental Health Conditions of Cambodian Refugee Children and Adolescents. Doctoral dissertation, The Ohio State University).

(4) Prunier, Gérard (2009). Africa's World War: Congo, the Rwandan Genocide, and the Making of a Continental Catastrophe. Oxford: Oxford University Press. ISBN 978-0-19-537420-9, p. 26

(5) Rasmussen, A., and Annan, J. (2010). Predicting stress related to basic needs and safety in Darfur refugee camps: A structural and social ecological analysis. Journal of refugee studies. 23(1), 23-40.

(6) Crowley, C. (2009). The mental health needs of refugee children: a review of literature and implications for nurse practitioners. Journal of the American Academy of Nurse Practitioners. 21(6), 322-331.

(7) Fazel, M., Doll, H., and Stein, A. (2009). A school-based mental health intervention for refugee children: An exploratory study. Child Psychology and Psychiatry. 14(2), 297-309.

(8) Thabet, A. A., Ibraheem, A. N., Shivram, R., Winter, E. A., and Vostanis, P. (2009). Parenting support and PTSD in children of a war zone. International Journal of Social Psychiatry. 55(3), 226-237.

(9) Onyut, L. P., Neuner, F., Ertl, V., Schauer, E., Odenwald, M., and Elbert, T. (2009). Trauma, poverty and mental health among Somali and Rwandese refugees living in an African refugee settlement–an epidemiological study. Conflict and health. 3(1), 6.

(10) Reedy, J. (2007). The Mental Health Conditions of Cambodian Refugee Children and Adolescents (Doctoral dissertation, The Ohio State University).

(11) Horn, R. (2010). A study of the emotional and psychological well-being of refugees in Kakuma refugee camp, Kenya. International Journal of Migration, Health and Social Care. 5(4), 20.

(12) Eggers, D. What is the What; the Autobiography of Valentino Achak Deng. (New York: Random House, 2006), 88.

(13) Fazel, M., Doll, H., & Stein, A. (2009). A school-based mental health intervention for refugee children: An exploratory study. Clinical Child Psychology and Psychiatry. 14(2), 297-309.

(14) Crowley, C. (2009). The mental health needs of refugee children: a review of literature and implications for nurse practitioners. Journal of the American Academy of Nurse Practitioners. 21(6), 322-331.

(15) Eggers, D. What is the What; the Autobiography of Valentino Achak Deng. (New York: Random House, 2006), 147.

(16) Odeh, Michael and Sullivan, Colin. Youth Advocate Program International Resource Paper. Recent Developments in Rehabilitation of Child Soldiers, Children in Armed Conflict. http://yapi.org/wp-content/uploads/2014/01/report-child-soldier-rehab.pdf.

(17) Pumariega, A. J., Rothe, E., and Pumariega, J. B. (2005). Mental health of immigrants and refugees. Community mental health journal. 41(5), 581-597.

(18) Thabet, A. A., Ibraheem, A. N., Shivram, R., Winter, E. A., and Vostanis, P. (2009). Parenting support and PTSD in children of a war zone. International Journal of Social Psychiatry. 55(3), 226-237.

(19) Onyut, L. P., Neuner, F., Ertl, V., Schauer, E., Odenwald, M., and Elbert, T. (2009). Trauma, poverty and mental health among Somali and Rwandese refugees living in an African refugee settlement–an epidemiological study. Conflict and health. 3(1), 6.

(20) Crowley, C. (2009). The mental health needs of refugee children: a review of literature and implications for nurse practitioners. Journal of the American Academy of Nurse Practitioners. 21(6), 322-331.

(21) Lamberg, L. (2008). Psychiatrists strive to help children heal mental wounds from war and disasters. JAMA. 300(6), 642-643.